Editorial Director: Dr Abraham Marcus Manaping Editor: Anne Patterson
@ Update Publications Ltd, 1981
As an editor and reader of many articles on medical education, one comes to recognize the most frequent varieties of article. A very common type describes how a large number of medical schools, deans, hospitals, or individual teachers or doctors were sent a questionnaire and their responses are tabulated in the form of simple frequencies. Those responsible for such studies are often individuals who have realised that this is the easiest possible way to do something which can be called research and to produce something that may get published. It is also often the format of surveys undertaken by groups, departments, and even the General Medical Council. One problem with the growing popularity of this technique is that answering, declining to answer, delegating, or avoiding such questionnaires has become a significant time commitment and occupational hazard of deans, departmental and programme chairmen, and few of us are free from sporadic outbreaks of such requests. No one wants to be unfriendly or obstructive to a colleague with a project, yet many resent being expected repeatedly to serve as a combination of unrewarded experimental animal and unpaid research assistant. This ‘research’technique usually entails many other people putting more work into it than the eventual author. Another problem is that, with relatively few exceptions, such studies are ineptly designed, and doomed to produce unreliable data. Though there is an established research methodology for designing, testing and administering questionnaires, it is rarely followed by the legions of questionnaire writers. The questions are often naive, ill-phrased, ambiguous, or leading- technically so structured as to be unable to produce the desired result or to be incapable of producing any other. There is little concern and even less capacity to control who actually answers the questionnaires, whether they are dealt with by the person most able to give valid and reliable answers, and whether the data thus provided are soundly based or fanciful estimates. Validity or reliability checks seem unknown within such studies. Unimaginative analysis and presentation of data is the rule. While it seems useful periodically to obtain an overview on a national scale of what is being done rather than what is believed to be going on, this is probably best done in occasional major surveys with the involvement of significant experts and optimal resources and methodology. This was done, for example, in the 1960-68 ASME Survey for the Royal Commission on Medical Education (HMSO, 1968) and the 1973-75General Medical Council Study (1977). The final and much neglected problem is what, if anything, one can and should do with the data that result. Such studies are often reminiscent of the reports of 19th century naturalists after their visits to remote islands. So, we are told that divorced lady dermatologists in the Western Isles spend an average of 4.73 hours per week on continuing medical education, or that our medical schools spend an average of 45 hours teaching omphalology, with a range of from 2 to 117 hours. Such data may, in Chomsky’s phrase, have the virtue of
Medical Teacher V o l 3 No 1 1981
K
Consultant Editor: Dr Michael A. Simpson Subeditor: Sue Kay
Med Teach Downloaded from informahealthcare.com by University of Toronto on 12/30/14 For personal use only.
Educational Inflation
Editorial Department: Update Publications Ltd 33/34 Alfred Place London WClE 7DP, England Tel: 01-637 4544 Subscription and Circulation Department: Update Publications Ltd 2 High Street Petersfield, Hampshire GU32 3JE Subscription Rates: Annual Subscription UK: 213.00 Overseas: 215.00 Air Mail: 220.00
Contributions: Contributions are invited in the form of original papers, articles of discussion and comment on all aspects of health sciences education. Prospective contributors should write to the Managing Editor, Medical Teacher, Update Publications Ltd, 33/34 Alfred Place, London WClE 7DP, England, before submitting manuscripts. Medical Teacher is published quarterly.
being true without the virtue of being interesting. What conclusions can be drawn, and what should we do about it?
Med Teach Downloaded from informahealthcare.com by University of Toronto on 12/30/14 For personal use only.
Absurdity of the ‘Hours League’ Potential conclusions are often ignored. If one school needs only two hours to teach omphalology and produces average and adequate doctors, isn’t St Brides-in-the-Bath grossly overdoing it with 117 hours? Sadly, such data never seem to be used to support the wholesome activity of reducing curriculum content. Instead, like wage claims, it leads to ‘catching-up’pleas from those endowed with fewer hours, and to the continuing problem of educational inflation. The lesser endowed use this as evidence supporting their old complaint that they cannot possibly teach ‘X’ in less than ‘Y’ hours. In fact, the findings of all such studies can be taken to support the Null Hypothesis, or at least the view that most people turn out to be pretty good doctors’ whatever you do to them, and that no particular number of hours of anything is essential for success. It also helps to demonstrate the absurdity of trying to measure or describe the educational experience in the most irrelevant units available-hours. The hours league reads like a group of old men boasting of their virility-the quality of the performance escapes comment, but they can always remember exactly how often. The whole questionnaire gambit and its attendant industry regrettably enhances our irrational preference for things we can count, rather than for things that really count. Michael A . Simpson, MD Associate Professor Department of Psychiatry Temple University, Philadelphia References
Report o f t h e Royal Commission on Medical Education, CMND 3569, HMSO, London, 1968. Basic Medical Education in the British Isles: The Report of the General Medicine Cbuncil Survey, Nuffield Provincial Hospitals Trust, London, 1977.
Continuing Education and the Process of Change Continuing education certainly continues. It continues as a topic for debate and it continues, according to at least some opinions, to be rather ineffective. The extent of the debate is illustrated by numerous articles in the journals and at least four reports produced by WHO on continuing education policies and procedures. Yet Bertram and Brooks-Bertram (1977) in a review of this literature .(mainly concentrating on North American sources) reported rather obliquely: “Evaluation providing strong assurances of valid results was not often found’. So it is of more than passing interest to read the most recent WHO
Medical Teacher V o l 3 No 1 1981
publication on this theme - Continuing Education of Health Personnel and Its Evaluation- to find out whether more effective approaches are available. The importance of continuing education has long been established- at least in principle. Eighty years ago William Osler (1900) gave an address on this theme which was reported in the Lancet. Essentially, the wellworn argument stresses the need for updating knowledge and skills in view of the rapid rate of change of medical practice resulting from new technological, scientific and sociological developments in the provision of health care. Other frequently expressed needs are to refresh memories of what was originally learnt some time ago and to maintain standards. These needs are likely to become even more pressing over the coming decade in view of the enormous international expansion in the number of health personnel trained. Currently, a high proportion of these people have been quite recently trained: in another 10 years or so the proportion of recently trained personnel must inevitably decrease. Quite a different and controversial function may well arise as a result of current criticisms of the initial medical training. Ian Kennedy (1980), in the recent Reith Lectures, described the training a’s inappropriate for the health needs of our society in the UK. Internationally, Fulop (1980) has commented that “curricula, methods and evaluation for the training of health workers are unsuitable for meeting community health needs”. If these criticisms are well founded, then continuing education has the additional burden of putting right the defects of the initial training programmes. What does the latest WHO report offer? Within its 40 pages it contains a report of a technical discussion and the various documents on which the discussion was based. Whilst no clear set of policies is presented, embedded within the text several helpful approaches are suggested. For example, continuing education is seen ideally as a multi-professional activity although, as is pointed out, “there is a danger of hoping for too much from multiprofessional courses”. The point is also emphasized that “continuing education must be directed to real practical needs and be related to the quality of health care rather than the special requirements of professional groups and academic disciplines”. Where the report deals with methods, acknowledgement is made of the role of reading and of informal discussion, but overall the impression remains that authors view continuing education as a formal programme of courses. There is also mention of the desirability of self-evaluation, and the point is made that whilst most self-evaluation activities are restricted solely to knowledge, there is no reason why health professionals should not also assess their own performance using methods such as self-audit. T h e Process of Change Overall, there is little feeling conveyed that the authors of the report really believe that existing continuing education methods work- indeed evidence is presented to the contrary. This, of course, leads to a paradox. Formal
7
*The lecture *Small group teaching *Independent learning
continuing education appears to be ineffective, yet there can be little doubt that health professionals do change the way in which they provide health care. This process of change would seem to depend on a combination of influences, rather than on any single factor. Perhaps the popular press, the chat in the bar, the TV programme and the visit from the drug company rep. all have a vital role to play. It would seem that an effective continuing education programme would depend on an understanding of how all the educational influences combine to lead to change in health care practice. When our understanding of this process is somewhat clearer more effective policies can be devised. The immediate need is to undertake research into this existing process of change. One approach to this research would be to consider the changes which individual health professionals have made in the way they work and to trace back the influences which had led to this change. In this way one can find out what has been shown to work and then build a continuing education programme on this evidence. F. R. Abbatt, B.SC, ED.M Senior Lecturer Department of International Community Health Liverpool School of Tropical Medicine, UK
Participants will develop teaching materials for use in their own institution.
References
Course in Medical Education
Med Teach Downloaded from informahealthcare.com by University of Toronto on 12/30/14 For personal use only.
This course will be held at the Centre for Medical Education, The University, Dundee, DDI 4HN, Scotland, from 16 March-7 April 1981. It is aimed at staff concerned with undergraduate, postgraduate or continuing medical education and teachers of paramedical workers. The emphasis throughout will be on the practical application of ideas and during the course participants will discuss the implications of some new and old techniques in their own situation, inspect samples, talk with teachers who have implemented new ideas and prepare teaching and assessment material for their own situation. The course consists of four modules, which can be taken individually:
1. Teaching Methods (16-20March)
2. Assessment and the Curriculum (23-27March) *Assessing knowledge *Assessing practical and clinical skills *Assessingattitudes Participants will develop assessment instruments for use in their own institution. 3. Management and Administration i n Medical Education (30 March-3 April) *Organization of courses *Organization of a curriculum *Introducing changes in a curriculum *Organization of examinations *Establishment of a learning resources centre *Support services for medical education 4. Recent Developments in Medical Education
(6-7April) *Modern educational principles: problem-based learning, self-assessment, feedback *Technical facilities: telephone, post, print, overhead projectors, latent image printing, computers, microprocessors Further details are available from the Centre at the above address or telephone Dundee (0382) 23 181 ext. 617 or Dundee 60111 ext. 2286.
8
Continuing Education of Health Personnel and its Evaluation, WHO. EURO Reports and Studies No. 33. William Osler, The importance of postgraduate study, The Lancet, July 14, 1900. Bertram, D. and Brooks-Bertram, P., The Evaluation of Continuing Medical Education: A Litwature Review, Health Education Monographs, Vol. 5 , No. 4, 1977. Fulop, T., Education and health care, Medical Education, 1980, 14, Supplement 1. Ian Kennedy, Unmasking Medicine, The Reith Lectures, British Broadcasting Corporation, 1980.
Medical Teacher-Two Years On Medical Teacher is now entering its third year of publication, during which time it has become essential reading for many teachers in medicine and the other health sciences. In recognition of the valuable role it plays, Glaxo Laboratories Ltd, Allen & Hanburys Ltd and Duncan, Flockhart & Co Ltd have undertaken to sponsor Medical Teacher, to be circulated free of charge to a limited number of people in the United Kingdom on a quarterly basis. We thank them for their generosity and farsightedness. Update Publications Ltd will continue to defray costs for subscription copies circulated to other readers, including those outside the United Kingdom. The revised subscription rates for those not entitled to receive free copies are as follows: UK, 513; overseas and Eire, 515; airmail, 220. We wish all our readers a happy and prosperous new year. Medical Teacher V o l 3 No 1 1981
@ Update Publications Ltd, 1981
As an editor and reader of many articles on medical education, one comes to recognize the most frequent varieties of article. A very common type describes how a large number of medical schools, deans, hospitals, or individual teachers or doctors were sent a questionnaire and their responses are tabulated in the form of simple frequencies. Those responsible for such studies are often individuals who have realised that this is the easiest possible way to do something which can be called research and to produce something that may get published. It is also often the format of surveys undertaken by groups, departments, and even the General Medical Council. One problem with the growing popularity of this technique is that answering, declining to answer, delegating, or avoiding such questionnaires has become a significant time commitment and occupational hazard of deans, departmental and programme chairmen, and few of us are free from sporadic outbreaks of such requests. No one wants to be unfriendly or obstructive to a colleague with a project, yet many resent being expected repeatedly to serve as a combination of unrewarded experimental animal and unpaid research assistant. This ‘research’technique usually entails many other people putting more work into it than the eventual author. Another problem is that, with relatively few exceptions, such studies are ineptly designed, and doomed to produce unreliable data. Though there is an established research methodology for designing, testing and administering questionnaires, it is rarely followed by the legions of questionnaire writers. The questions are often naive, ill-phrased, ambiguous, or leading- technically so structured as to be unable to produce the desired result or to be incapable of producing any other. There is little concern and even less capacity to control who actually answers the questionnaires, whether they are dealt with by the person most able to give valid and reliable answers, and whether the data thus provided are soundly based or fanciful estimates. Validity or reliability checks seem unknown within such studies. Unimaginative analysis and presentation of data is the rule. While it seems useful periodically to obtain an overview on a national scale of what is being done rather than what is believed to be going on, this is probably best done in occasional major surveys with the involvement of significant experts and optimal resources and methodology. This was done, for example, in the 1960-68 ASME Survey for the Royal Commission on Medical Education (HMSO, 1968) and the 1973-75General Medical Council Study (1977). The final and much neglected problem is what, if anything, one can and should do with the data that result. Such studies are often reminiscent of the reports of 19th century naturalists after their visits to remote islands. So, we are told that divorced lady dermatologists in the Western Isles spend an average of 4.73 hours per week on continuing medical education, or that our medical schools spend an average of 45 hours teaching omphalology, with a range of from 2 to 117 hours. Such data may, in Chomsky’s phrase, have the virtue of
Medical Teacher V o l 3 No 1 1981
K
Consultant Editor: Dr Michael A. Simpson Subeditor: Sue Kay
Med Teach Downloaded from informahealthcare.com by University of Toronto on 12/30/14 For personal use only.
Educational Inflation
Editorial Department: Update Publications Ltd 33/34 Alfred Place London WClE 7DP, England Tel: 01-637 4544 Subscription and Circulation Department: Update Publications Ltd 2 High Street Petersfield, Hampshire GU32 3JE Subscription Rates: Annual Subscription UK: 213.00 Overseas: 215.00 Air Mail: 220.00
Contributions: Contributions are invited in the form of original papers, articles of discussion and comment on all aspects of health sciences education. Prospective contributors should write to the Managing Editor, Medical Teacher, Update Publications Ltd, 33/34 Alfred Place, London WClE 7DP, England, before submitting manuscripts. Medical Teacher is published quarterly.
being true without the virtue of being interesting. What conclusions can be drawn, and what should we do about it?
Med Teach Downloaded from informahealthcare.com by University of Toronto on 12/30/14 For personal use only.
Absurdity of the ‘Hours League’ Potential conclusions are often ignored. If one school needs only two hours to teach omphalology and produces average and adequate doctors, isn’t St Brides-in-the-Bath grossly overdoing it with 117 hours? Sadly, such data never seem to be used to support the wholesome activity of reducing curriculum content. Instead, like wage claims, it leads to ‘catching-up’pleas from those endowed with fewer hours, and to the continuing problem of educational inflation. The lesser endowed use this as evidence supporting their old complaint that they cannot possibly teach ‘X’ in less than ‘Y’ hours. In fact, the findings of all such studies can be taken to support the Null Hypothesis, or at least the view that most people turn out to be pretty good doctors’ whatever you do to them, and that no particular number of hours of anything is essential for success. It also helps to demonstrate the absurdity of trying to measure or describe the educational experience in the most irrelevant units available-hours. The hours league reads like a group of old men boasting of their virility-the quality of the performance escapes comment, but they can always remember exactly how often. The whole questionnaire gambit and its attendant industry regrettably enhances our irrational preference for things we can count, rather than for things that really count. Michael A . Simpson, MD Associate Professor Department of Psychiatry Temple University, Philadelphia References
Report o f t h e Royal Commission on Medical Education, CMND 3569, HMSO, London, 1968. Basic Medical Education in the British Isles: The Report of the General Medicine Cbuncil Survey, Nuffield Provincial Hospitals Trust, London, 1977.
Continuing Education and the Process of Change Continuing education certainly continues. It continues as a topic for debate and it continues, according to at least some opinions, to be rather ineffective. The extent of the debate is illustrated by numerous articles in the journals and at least four reports produced by WHO on continuing education policies and procedures. Yet Bertram and Brooks-Bertram (1977) in a review of this literature .(mainly concentrating on North American sources) reported rather obliquely: “Evaluation providing strong assurances of valid results was not often found’. So it is of more than passing interest to read the most recent WHO
Medical Teacher V o l 3 No 1 1981
publication on this theme - Continuing Education of Health Personnel and Its Evaluation- to find out whether more effective approaches are available. The importance of continuing education has long been established- at least in principle. Eighty years ago William Osler (1900) gave an address on this theme which was reported in the Lancet. Essentially, the wellworn argument stresses the need for updating knowledge and skills in view of the rapid rate of change of medical practice resulting from new technological, scientific and sociological developments in the provision of health care. Other frequently expressed needs are to refresh memories of what was originally learnt some time ago and to maintain standards. These needs are likely to become even more pressing over the coming decade in view of the enormous international expansion in the number of health personnel trained. Currently, a high proportion of these people have been quite recently trained: in another 10 years or so the proportion of recently trained personnel must inevitably decrease. Quite a different and controversial function may well arise as a result of current criticisms of the initial medical training. Ian Kennedy (1980), in the recent Reith Lectures, described the training a’s inappropriate for the health needs of our society in the UK. Internationally, Fulop (1980) has commented that “curricula, methods and evaluation for the training of health workers are unsuitable for meeting community health needs”. If these criticisms are well founded, then continuing education has the additional burden of putting right the defects of the initial training programmes. What does the latest WHO report offer? Within its 40 pages it contains a report of a technical discussion and the various documents on which the discussion was based. Whilst no clear set of policies is presented, embedded within the text several helpful approaches are suggested. For example, continuing education is seen ideally as a multi-professional activity although, as is pointed out, “there is a danger of hoping for too much from multiprofessional courses”. The point is also emphasized that “continuing education must be directed to real practical needs and be related to the quality of health care rather than the special requirements of professional groups and academic disciplines”. Where the report deals with methods, acknowledgement is made of the role of reading and of informal discussion, but overall the impression remains that authors view continuing education as a formal programme of courses. There is also mention of the desirability of self-evaluation, and the point is made that whilst most self-evaluation activities are restricted solely to knowledge, there is no reason why health professionals should not also assess their own performance using methods such as self-audit. T h e Process of Change Overall, there is little feeling conveyed that the authors of the report really believe that existing continuing education methods work- indeed evidence is presented to the contrary. This, of course, leads to a paradox. Formal
7
*The lecture *Small group teaching *Independent learning
continuing education appears to be ineffective, yet there can be little doubt that health professionals do change the way in which they provide health care. This process of change would seem to depend on a combination of influences, rather than on any single factor. Perhaps the popular press, the chat in the bar, the TV programme and the visit from the drug company rep. all have a vital role to play. It would seem that an effective continuing education programme would depend on an understanding of how all the educational influences combine to lead to change in health care practice. When our understanding of this process is somewhat clearer more effective policies can be devised. The immediate need is to undertake research into this existing process of change. One approach to this research would be to consider the changes which individual health professionals have made in the way they work and to trace back the influences which had led to this change. In this way one can find out what has been shown to work and then build a continuing education programme on this evidence. F. R. Abbatt, B.SC, ED.M Senior Lecturer Department of International Community Health Liverpool School of Tropical Medicine, UK
Participants will develop teaching materials for use in their own institution.
References
Course in Medical Education
Med Teach Downloaded from informahealthcare.com by University of Toronto on 12/30/14 For personal use only.
This course will be held at the Centre for Medical Education, The University, Dundee, DDI 4HN, Scotland, from 16 March-7 April 1981. It is aimed at staff concerned with undergraduate, postgraduate or continuing medical education and teachers of paramedical workers. The emphasis throughout will be on the practical application of ideas and during the course participants will discuss the implications of some new and old techniques in their own situation, inspect samples, talk with teachers who have implemented new ideas and prepare teaching and assessment material for their own situation. The course consists of four modules, which can be taken individually:
1. Teaching Methods (16-20March)
2. Assessment and the Curriculum (23-27March) *Assessing knowledge *Assessing practical and clinical skills *Assessingattitudes Participants will develop assessment instruments for use in their own institution. 3. Management and Administration i n Medical Education (30 March-3 April) *Organization of courses *Organization of a curriculum *Introducing changes in a curriculum *Organization of examinations *Establishment of a learning resources centre *Support services for medical education 4. Recent Developments in Medical Education
(6-7April) *Modern educational principles: problem-based learning, self-assessment, feedback *Technical facilities: telephone, post, print, overhead projectors, latent image printing, computers, microprocessors Further details are available from the Centre at the above address or telephone Dundee (0382) 23 181 ext. 617 or Dundee 60111 ext. 2286.
8
Continuing Education of Health Personnel and its Evaluation, WHO. EURO Reports and Studies No. 33. William Osler, The importance of postgraduate study, The Lancet, July 14, 1900. Bertram, D. and Brooks-Bertram, P., The Evaluation of Continuing Medical Education: A Litwature Review, Health Education Monographs, Vol. 5 , No. 4, 1977. Fulop, T., Education and health care, Medical Education, 1980, 14, Supplement 1. Ian Kennedy, Unmasking Medicine, The Reith Lectures, British Broadcasting Corporation, 1980.
Medical Teacher-Two Years On Medical Teacher is now entering its third year of publication, during which time it has become essential reading for many teachers in medicine and the other health sciences. In recognition of the valuable role it plays, Glaxo Laboratories Ltd, Allen & Hanburys Ltd and Duncan, Flockhart & Co Ltd have undertaken to sponsor Medical Teacher, to be circulated free of charge to a limited number of people in the United Kingdom on a quarterly basis. We thank them for their generosity and farsightedness. Update Publications Ltd will continue to defray costs for subscription copies circulated to other readers, including those outside the United Kingdom. The revised subscription rates for those not entitled to receive free copies are as follows: UK, 513; overseas and Eire, 515; airmail, 220. We wish all our readers a happy and prosperous new year. Medical Teacher V o l 3 No 1 1981
